Concussions & Post-Concussive Syndrome

Let’s broach a hot topic.

In 2012, the who’s-who of the concussion world got together in Zurich to write a consensus statement on the matter. Basically, what they found was that we have come a long way in concussion awareness in both the public and medical spheres, but we still have a long ways to go in terms of treatment and prolonged-symptom management.

What is a Concussion?

The Zurich consensus defines a concussion as “a brain injury and complex pathophysiological process affecting the brain, induced by biomechanical forces“. A concussion may be caused by a direct blow to the head, face, or neck or any indirect blow to the body with an “impulsive” force transmitted to the head. (As in, you got your bell rung.) It usually results in a rapid onset of neurological impairment, though in some cases it may take some time for symptoms to present. Despite the often drastic and debilitating symptomology, there are typically no abnormalities seen in standard imaging (like x-rays and MRIs).

Symptoms of a concussion will present in one or more of the following clinical domains:

  1. Subjective Symptoms: somatic (headaches), cognitive (fog), and/or emotional (mood lability)
  2. Physical Signs: loss of consciousness, amnesia, sensitivity to light
  3. Behavioral Changes: irritability, anxiety, mood swings
  4. Cognitive Impairment: slowed reaction times, difficulty concentrating
  5. Sleep Disturbance: insomnia, chronic fatigue syndrome

A detailed physical and cognitive assessment by a trainer or physician should be done and should include a SCAT3 (that you should keep on record to monitor baseline and progression).

Return to Play

Believe it or not, there is no official consensus or strong evidence support for the amount of rest needed during the acute phase of a concussion. However, an initial 24-48 hour rest period is still considered good advice. There is no support for waking someone up or not allowing someone with a suspected concussion to sleep. If you are a concerned parent and that thought stresses you out, it is ok for you to be watchful and check on your children, but please do not wake them up every hour. The brain needs sleep to heal!

Low-level exercise after a short period (1-2 days) of rest may be beneficial for those slow to recover. The best evidence today supports a structured graduated return to play protocol (outlined below). Heading back to full activity too soon can put you in a very vulnerable position and you may be more susceptible to a second concussion, so play it smart.

What is Post-Concussive Syndrome?

Brain LighteningAccording to the Zurich consensus, 80 to 90% of concussions resolve within 7 to 10 days. Children and adolescents may take a little longer to resolve than adults. The body has an amazing capacity to heal and for most people, a little time will do the trick.

Anyone whose symptoms last longer than 10 days is considered to have post-concussive syndrome. This is bit more of a complex game we are playing now. (Especially considering I have patients who come in still experiencing symptoms years later.)

There are several factors that may increase your risk of experiencing prolonged or persistent symptoms after a concussion. These modifiers include age (less than 18 years old), prolonged loss of consciousness (more than 1 minute), number of previous concussions, multiple concussions in a short period of time, comorbidities (including migraines, mood disorders, ADHD, learning disabilities, and sleep disorders), medications (in particular antidepressants and anticoagulants), and dangerous style of play or high-risk activity.

In my experience, those suffering from post-concussive syndrome experience some combination of headaches, ear symptoms, musculoskeletal pain or tightness (especially of the neck), sleep disturbance (both chronic fatigue syndrome and insomnia), mood disorders (including depression, anxiety, and obsessive-compulsive tendencies), and cognitive impairment (including inability to concentrate, sudden onset dyslexia, brain fog, and loss of balance).   These symptoms can be mild, transient, variable, or consistent.

What do you do to treat it?

The Zurich consensus recommendation for treating concussions with symptoms lasting more than 10 days is to “be managed by a multidisciplinary manner by healthcare providers with experience in sports-related concussion”. There are no specific guidelines for that multidisciplinary team of healthcare providers. I am not an expert in sport-induced concussions; my specialty is in developmental neurology. However, people suffering from post-concussive syndrome (and those who want to deliberately avoid doing so) seem to come out of the woodwork. Here is the basic approach that I take to support brain healing in these individuals.

  1. Nutritional support for brain inflammation and healing.
    1. This helps put your body in healing mode and supports healthy brain chemistry. (This is likely to include food based and nutriceutical support.)
  2. Neurosensory dysfunction screening and integration.
    1. This helps establish good brain-body communication on a foundational (developmental), reflexive level. (In my experience, the visual and vestibular systems tend to be taxed in my PCS patients.)
  3. Chiropractic care and CranioSacral Therapy.
    1. This helps establish good communication between the joints of the spine and the brain and balance autonomic nervous system dysfunction. (Sympathetic overdrive is one possible dynamic active in PCS.)
  4. Customized enhanced support and home care.
    1. This is the mixed bag that is unique to each patient and their case. It may include soft tissue therapy (whether self-myofascial-release (SMR) or from a qualified practitioner) to support whatever physical injuries were sustained, movement-based therapy, exercise rehab, or more advanced nutritional support for sleep, brain function, or whatever else that specific patient has hanging around.

I very much support a multidisciplinary approach to co-manage a post-concussive patient. I may refer to a vestibular physiotherapist, a counselor or psychologist, a Medical Doctor or neurologist, a Registered Massage Therapist, or even a trainer/kinesiologist depending on the case. One thing to remember is there should be ample communication and collaboration between this group to maintain the patient’s best interest and this generally works best if there is one “lead”.

I hope this helps you on your journey to getting your life back after a concussion.

If you are looking for a knowledgeable health care practitioner to help you assess or treat a concussion, Dr. Benjamin Stevens and Dr. Shannon Snow are both experienced sport practitioners skilled at assessing concussion and guiding you during the acute phase. Dr. Amanda Stevens (who wrote this article) works more with the “tricky” post-concussive cases.

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